Breast cancer (mastocarcinoma) is the most common form of cancer among women. Consequently, it will be encountered by doctors as part of their work in hospitals and medical practice. This disease exhibits a heterogeneous pattern including different histological subtypes, which may differ considerably in their degree of malignity and, consequently, in their clinical symptoms and therapy. The following article helps you to understand the clinical picture of mastocarcinoma, identify its symptoms and to classify its histology correctly.

00:01
Classification: In situ,
ductal and lobular.
00:05
Stop here for one second.
00:07
What does in situ mean to you?Malignancy.
00:11
What’s the difference
between this and invasive?In situ, the basement
membrane is intactand if it’s ductal,
can you picture it?Major terminal duct and
the membrane’s intact.
00:25
I’d walk you through
comedocarcinoma already.
00:28
Lobular carcinoma in situ,the lobule and its
membrane will be intact.
00:32
What happens now?There’s every possibility thatthe basement membrane is
then going to rupture.
00:37
Welcome to invasive.
00:39
Would you please tell me as
to what is the most commoninvasive breast cancer?It’s this one.
00:46
Invasive ductal cancer.
00:48
Lobular carninoma,
invasive type.
00:51
Upon histology,it would show you those cellsthat would be all marching
one behind the other.
00:59
And this is the one
that loves to spread.
01:01
This is the one that loves tospread to the other breast
in fact, contralateral.
01:07
Non-invasive with in situ:Malignant population of cells
that lack the capacity to invade.
01:13
Acini are distorted,unfolded and take
appearance of small ducts.
01:17
Non-invasive in situ.
01:20
With in situ, special subtype,we’ll walk you through
comedocarcinoma.
01:23
What does that mean to you?This means that inside
the actual tumor,you’d find areas
that are necrotic,characterized by solid sheets
of high-grade malignant cellsand central necrosis.
01:34
Comedo-, comedocarcinoma.
01:37
There’s another subtype here,punctate area of necrotic material
with comedone-like appearance.
01:44
The other subtype,I’m not going to spend
so much time with,but you pay attention
to the comedo,which to you should mean
central, necrotic areas.
01:54
Now what’s interesting about
this one is the following:First, take a look at the histologic
picture and you find Paget cells.
02:01
The Paget cells are
filled with mucinand it would stain for
positive periodic acid-Schiff.
02:07
"So why in the world, Dr. Raj, are
you talking about ductal carcinomain situ and show me a
picture of Paget’s?Before we begin,can you picture the patient with
Paget’s disease in the nippleand how she’s presenting.
02:19
Either by picture or
through description.
02:22
There’s an eczematous --
eczematous -- rash on the nipple.
02:26
Eczematous, not like
skin of an orange.
02:29
And when I briefly walk you
through Paget’s disease,I told you that there would
have been underlying disease.
02:37
This is what I’m referring to.
02:39
Ductal carcninoma in situ,the one subtype we talked about
earlier was comedocarcinoma.
02:46
Keep that separate.
02:47
Paget’s disease of the nipple which
looks like eczema on the nipple.
02:50
Picture that first.
02:52
Histology shows you Paget cells.
02:55
The other time that I’ve
shown you Paget cells wasextramammary with vulva.
03:01
Ductal carcinoma in situ that
extends from the nipple ductinto the contiguous skin
of the nipple and areola,the underlying cancer that
you’re worried about heremost of the time with
Paget’s would be DCIS.
03:15
The nipple and areola are
frequently fissured, ulceratedand oozing because of extreme
involvement of the nipple itself.
03:24
So you want to be really carefuland organize your thought here,ductal carcinoma in situ,comedocarcinoma,ductal carcinoma in situ
being the underlyingmalignancy for Paget’s
disease of the nipple.
03:36
With the duct being involved,thus you would find there
to be nipple and areolathat are often involved with
fissures, ulcerations and oozing.
03:48
Now, let’s move on to
lobular carcinoma in situ.
03:51
First, think about the lobule.
03:54
Back deep by the
stroma, the lobule.
03:57
Manifested by proliferation in one
or more terminal duct or ductulealong with the lobule.
04:02
Here, you’d find more or
less your Signet ring cells.
04:05
Stop here for one second.
04:07
Doesn’t that sound
awfully familiar?Signet ring? I know
that, I know that.
04:12
I know you do.
04:13
The last time we talked about this was
gastric adenocarcinoma, diffuse type.
04:19
And also we talked about
this in ovarian cancer.
04:23
Do you remember how you can
find the Signet ring cellsin an ovary or histologic
picture of an ovary.
04:29
Krukenberg.
04:30
Exactly, very good.
04:31
So why is Signet-ring cell
here and what kind of –"Dr. Raj, I know you’re
going bring in parallel."Of course, I am.
04:39
And this is more
molecular in nature.
04:42
Molecularly speaking, your diffuse
type of gastric adenocarcinomaand the lobular carcinoma,
they love to spread.
04:51
They’re both
E-cadherin negative.
04:53
Keep that in mind,especially as we get into
invasive lobular cancer.
04:58
So therefore, interesting
enough, two major cancersthat are E-cadherin negative
contain Signet ring cells,which are filled with mucin.
05:09
Distends glandular acini.
05:12
Invasive cancer.
05:14
So what does invasive
cancer mean to you?Invasive carcinoma
will be one in whichmarked by increased and
dense fibrous stromagiving a stoney hard
– feel your chin.
05:26
It feels like this, gritty.
05:28
Really gritty.
05:31
Corresponds to
histologic desmoplasia.
05:33
Stop here for one second.
05:35
Big time important.
05:36
Invasive pathology.
05:37
You’ve learned
about a phenomenonthat takes place
with adenocarcinomain which the surrounding tissues
undergo a fibrous change.
05:46
Some pathologist will
call it fibroplasia.
05:49
Some pathologist and
on your boards,they most likely will
call it desmoplasia.
05:53
So it’s a non-neoplastic
but it’s fibrous.
05:56
Trying to wall off the invasion is
what the response is trying to do,but in the process,it actually makes it difficult for
chemotherapy to reach the cancer.
06:07
So where is their research?Guaranteed in your practice,
oncology especially,that you would be giving –or you were thinking about when
to give desmoplasia inhibitors.
06:20
If you remove the wall,it makes it easier to reach the
cancer cell, chemotherapy.
06:24
Big time important in
every way shape or form.
06:28
You may have
infiltrative attachmentto the surrounding
structure with fixation,the dimpling of the skin,
retraction of the nipple.
06:35
All of these is then known
part of your invasive cancer.
06:39
Invasive lobular cancer
is where we are.
06:41
These tend to be bilateral.
06:44
Remember,the most common
invasive would be your?Good.
06:48
Ductal.
06:49
You definitely want to know about
lobular invasive, however.
06:52
This is the one that
loves to spread.
06:55
Bilateral.
06:56
Multicentric.
06:57
E-cadherin negative.
06:59
Diffusely invasive pattern.
07:01
Frequently metastasize to where?Cerebrospinal fluid, ovary,
uterus, bone marrow.
07:07
All over the place.
07:09
The parallel that you want
to bring here once again,remember we’re talking
about Signet ring cells.
07:14
We talked about
E-cadherin negative.
07:16
This one loves to
spread as well.
07:18
Look at the places
it loves to spread.
07:19
Everywhere.
07:21
CSF, ovary, uterus, bone
marrow, so on and so forth.
07:24
This is medullary cancer.
07:26
BRCA1 is the gene here.
07:28
Soft, fleshy consistency.
07:30
Well-circumscribed is what you
would expect upon morphology.
07:34
Good prognosis.
07:35
Not a whole lot to
say about medullary,but you want to be familiar
or know that it exists.
07:41
Poor prognostic factors, however,
include high nuclear grade,aneuploidy,absence of hormone receptors,p53 expression,high proliferative rates.
07:54
So this would then make your
medullary cancer to be thenpoor prognostically.
07:59
Our topic here very importantly is
prognostic factors for breast cancer.
08:03
I’ve mentioned a
few times now thatthe most important prognostic
indicator would beaxillary lymph node spread.
08:09
Tumor size will then influence
your prognostication.
08:14
Estrogen and progesterone
receptor expressionwould then help you
with prognosisand if you find this
to be positive,then you have drugs at
your disposal such asyour partial agonist, tamoxifen.
08:27
If there is increased
proliferative rate,this then affects
your prognosis.
08:31
And over expression
or hyperexpressionof HER-2/neu has
worse prognosis.
08:37
However, we have a drugthat we are quite familiar
with,trastuzumab.

About the Lecture

The lecture Breast Cancer Classification by Carlo Raj, MD is from the course Breast Disease. It contains the following chapters:

Breast Carcinoma Classification

Differential Diagnosis of Non-Invasive Carcinoma

Differential Diagnosis of Invasive Carcinoma

Included Quiz Questions

Which of the following statements about comedonic carcinoma is INCORRECT?

It is a type of lobular carcinoma in situ.

It presents with solid sheets of high grade malignant cells with central necrosis.

All are incorrect.

It arises from a malignant population of ductal cells.

Punctate areas of necrotic material appear comedone-like.

What clinical manifestation of invasive lobular carcinoma is the least likely?

Retraction of nipple

Bilateral lesions

Frequently metastasize to CSF, ovary, uterus and bone marrow.

Often has diffusely invasive pattern

Multicentric lesions

Which of the following is NOT a poor prognostic factor in the setting of medullary carcinoma?

Polyploidy

High nuclear grade.

Hyperexpression of HER2/neu

Absence of hormone receptors

Increased tumor size

Which of the following is a type of breast carcinoma that is most likely to present with fissured, ulcerated and oozing from the nipple and areola area?

Paget’s disease with ductal carcinoma

Lobular carcinoma in situ

Phyllodes tumor

Invasive lobular carcinoma

Medullary carcinoma

Author of lecture Breast Cancer Classification

Carlo Raj, MD

Customer reviews

(4)
2,8 of 5 stars

5 Stars

1

4 Stars

1

3 Stars

0

2 Stars

0

1 Star

2

i don't like how professor articulate the words

By antonio p. on 10. May 2018 for Breast Cancer Classification

there is a higher difficulty to understand english for non-english people like me i prefer other professor.

Interesting

By Ibidunni B. on 14. December 2017 for Breast Cancer Classification

The lectures are pretty straight forward and interesting. I enjoy the fact that other aspects are always linked in Dr Raj's lectures.

Bad lecture

By Ibrahim A. on 11. October 2017 for Breast Cancer Classification

most of Dr. Raj lectures are very bad presented (( i dont like it at all ))

Thank you

By Svetlana K. on 24. August 2017 for Breast Cancer Classification

I really thought that the lecture was right on point and stressed the most important "boards" material. It was very well organized and presented! I am taking my USMLE step 2 CK in couple of days, and after months of intensive preparation for the exam, I realized that I have learned and reviewed so much that It sort of hard to keep it all organized and compartmentalized in my head. These videos definitely put things in perspective for me.
Thank you, Lana

User Reviews

(4)
2,8 of 5 stars

5 Stars

1

4 Stars

1

3 Stars

0

2 Stars

0

1 Star

2

i don't like how professor articulate the words

By antonio p. on 10. May 2018 for Breast Cancer Classification

there is a higher difficulty to understand english for non-english people like me i prefer other professor.

Interesting

By Ibidunni B. on 14. December 2017 for Breast Cancer Classification

The lectures are pretty straight forward and interesting. I enjoy the fact that other aspects are always linked in Dr Raj's lectures.

Bad lecture

By Ibrahim A. on 11. October 2017 for Breast Cancer Classification

most of Dr. Raj lectures are very bad presented (( i dont like it at all ))

Thank you

By Svetlana K. on 24. August 2017 for Breast Cancer Classification

I really thought that the lecture was right on point and stressed the most important "boards" material. It was very well organized and presented! I am taking my USMLE step 2 CK in couple of days, and after months of intensive preparation for the exam, I realized that I have learned and reviewed so much that It sort of hard to keep it all organized and compartmentalized in my head. These videos definitely put things in perspective for me.
Thank you, Lana

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